Lower Back and Hip Pathology Flashcards
lumbar disk herniation
defn and causes
wear and tear –> minor tears in annulus fibrosis –> major tears in annulus fibrosis –> protrusion of nucleus pulposa –> pain, possible radiculopathy and myelopathy d/t direct compression or inflammation
typically posteriolateral d/t typical pattern of anterior compression from frequent flexion e.g. bending and sitting
also posterior longitudinal ligament
lumbar disk herniation
radiculopathy clinical presentation
nerve root exits below level of lumbar disk (as opposed to cervical exiting above)
posterolateral herniation usually spares nerve root at that level and instead the next one below that (so L4 herniation would affect L5 nerve, which is below L5)
far lateral does not spare (L4 herniation would affect L4 root)
most common herniations are L4/L5 and L5/S1 –> most common radiculopathies at L5 and S1. both cause sciatica. sensory and/or motor involvement.
significant compression of thecal sac may also cause cauda syndrome – bowel and bladder incontinence, loss of motor and sensory in legs
else motor and/or sensory following any specific myotomal distribution
lumbar dis herniation
clinical presentation and PE findings
local low back pain, midline and/or paraspinals
worse with low back movement
bilateral paraspinal spasm
loss of lumbar lordosis
limited ROM d/t pain
radiculopathy - usually sciatica, foot drop also common –> abnormal gait
possible cauda equina syndrome – bowel and bladder incontinence, loss of motor and sensory to LE
special testing: straight leg raise for sciatica
lumbar disk herniation
tx and prognosis
pain relief +/- muscle relaxants +/- epidural corticosteriods
PT, traction, heat/ice
pain usually resolves in 6 weeks w/ conservative tx
radiculopathy and myelopathy have more complications, surgery may be needed
surgery indicated in cauda equina syndrome
L4/L5 lumbar disk herniation
sacroiliac joint dysfunction
defn and causes
changes in SI alignment d/t changes in ligament integrity
sitting and trauma –> short and tight SI ligaments
trauma and pregnancy –> lax
muscular imbalance –> SI stress
aging –> degeneration, uneven, possible fusion
ligament changes can result in inflammation, but not the same as sacroiliitis, which is inflammation not d/t ligment changes, such as in ankylosing spondylitis
lumbar muscle strain
muscle injury d/t exertion, overstretching, or overuse
most common cause of back pain, usually starts in lower back and migrates to hip and buttock
improper lifting technique is common cause of acute strain, esp in normally sedentary individuals or with particularly heavy object
most resolve quickly and spontaneously
paraspinal spasm –> loss of lumbar lordosis, limited ROM d/t pain and stiffness
chronic strain d/t muscle “bracing” (overuse of certain muscles to make up for others) d/t instability, ddd, herniation, stress and anxiety disorders — ie. concurrent muscle strain is common in other neck and back conditions
lumbar dermatomes
L2-3 anterior/mid-thigh
L4 knee and medial malleolus
L5 web b/w 1st and 2nd toe
S1 lateral malleolus
L5 and S1 are also associated with sciatica, but that’s not technically a dermatome
lumbar myotomes
L2-4 knee extension and hip aDduction
L5 ankle dorsiflexion (extension) and big toe extension
S1 ankle plantarflexion, knee flexion, hip extension (“tuck”)
lumbar radiculopathy
clinical presentation and PE findings
painful or antalgic gait
possible reactive paraspinal spasm w/ associated pain, stiffness, tenderness to palpation
limited ROM d/t pain/reproduction of sx
no tenderness to palpation in affected extremities
dermatomal paresthesia and/or myotomal weakness w/ possible loss of reflexes
special testing: straight leg raise, EMG
lumbar radiculopathy
tx and prognosis
NSAIDs for inflammatory pain + neuropathic pain meds +/- epidural corticosteroids
acute: laying supine for 2 days to reduce compression
chronic: PT, ergonomics, lifting techniques, weight loss if applicable
avoid lifting, stooping, bending, prolonged standing or sitting while active sx
lumbar traction (temporary)
if severe, surgical removal of underlying cause e.g. herniation or osteophytes
most sx resolve spontaneously w/ conservative tx
lumbar spinal stenosis
defn and causes
narrowing of central spinal canal
disk herniation, large osteophyte, hematoma s/p trauma or spinal procedure, tumor, foreign body
cervical spine: spinal cord compression
lumbar: cauda equina
anywhere: radiculopathy
spinal stenosis
clinical presentation and PE findings
usually progression of disk herniation, ddd, or spondylolythesis
multilevel bilateral sensory and motor – high suscpicion if this is present
lumbar: below level of lumbar, common complication is cauda equina syndrome
often stooped posture as this opens up canal and relieves sx
reduced muscle tone and hypo or areflexia
cervical: hyperreflexia of lower extremities and increased tone. upper motor neuron = uninhibited descending pathway; spurling’s sign: pain radiating down arm with neck extension
spinal stenosis + L4/L5 herniated disk
lumbar
spinal stenosis
tx and prognosis
pain management + oral corticosteroids for pain and weakness
epidural steroids not usually helpful - even small volume injections into already-tight space worsens sx
decompression surgery for osteophyte, disk, etc. removal may be needed; cervical and thoracic needs immediate surgical decompression d/t compression of spinal cord
mild stenosis from herniated disk usually resolves spontaneously
ddd, osteophytes, ligamentum flavum thickening, congenital short pedicles –> likely progressive
tx will typically prevent progression of but not reverse neurological deficits
spinal compression frx
collapsing or crushing bone d/t injury and/or weak structure
fall landing on butt or feet
osteoporosis
lower thoracic and thoracic-lumbar most common
cracks may not always be obvious on xray, look for height of vertebral body
spondylolysis
pars interarticularis frx
usually L5/S1
neck of “scotty dog” on xray
trauma w/ hyperextension, commonly gymnasts
5% overall lifetime incidence
spondylolysis = pars interarticularis frx
spondylolisthesis
vertebral slippage
spondylosis
any condition of the spine
avascular necrosis femoral head
bone death d/t no blood supply
d/t trauma, diabetes, sickle cell SLE, RA, chronic corticosteroids, chronic EtOH
or idiopathic i.e. legg-calve-perthes disease
collapse of bone and destruction of hip joint d/t early asymptomatic i.e. not caught early
groin pain worse with weight-bearing
sx may mimic OA
usually needs total hip replacement
avascular necrosis femoral head
posterior hip dislocation
more common than anterior
developmental or traumatic
high-energy blunt force trauma e.g. MVA, car vs ped, falling from height
internal rotation and aDduction of hip often w/ sciatic nerve compression
posterior hip dislocation
proximal femur frx
femoral neck or intertrochanteric
falls, elderly, osteoporosis
hip or groin pain
complication: AVN d/t damage to circumflex femoral artery branches
intertrochanteric femur frx
legg-calve-perthes disease
defn and causes
idiopathic avascular necrosis of femoral head
typical blood supply (artery of the ligament to the head of the femur) is gradually replaced by medial and lateral circumflex femoral artery supply
this makes femur more prone to AVN
almost exclusively in white boys 3-12 y/o, median 7 years
usually no trauma hx
legg-calve-perthes
clinical presentation and PE findings
insidious
mild hip or knee pain w/ limp, usually unilateral
if bilateral, not symmetric
decreased internal rotation and aBduction
3-12 y/o white boy
initial phase: normal radiographs
degenerative: flattened femoral head
regenerative: reossification of femoral head, but doesn’t fit right in acetabular cavity
legg-calves-perthes
degenerative phase
legg calve perthes
tx and prognosis
activity restriction or bedrest
casting, bracing, or surgical immobilization
kids remodel bone quickly, so early intervention usually allows femoral head to remold back into round shape
sacroiliac joint dysfx
clinical presentation and PE findings
low back and buttocks pain, may radiate to anterior or posterior thigh
deep, aching
gradual
worse with any hip movement, walking, standing, weight-bearing
worse with palpation over SI ligaments or near posterior superior iliac spine
+FABER (flexion, aBduction, external rotation
radiology usually normal
sacroiliac joint dysfx
tx and prognosis
NSAIDs
acute: ice
chronic: deep heat/ultrasound
glute and paraspinal strengthening
if refractory, injection with corticosteroid and/or proliferative agent + PT
usually self-limiting, esp if treated early
if tx delayed, can b//c chronic and debilitating
hip OA
progressive cartilage degeneration
groin pain, but w/o tenderness to palpation in inguinal area
ranges from dull, aching, throbbing, to sharp, stabbing
worse with weight-bearing
possible limp
restricted ROM d/t structural changes and pain - internal rotation and aBduction
non-uniform joint space narrowing, bone cyst, bone sclerosis, osteophytes
developmental hip dysplasia
aka congenital hip dislocation
poor fit b/w femoral head and acetabulum –> easy posterior subluxation
unilateral or bilateral
seems genetic, more in girls (80%)
newborn screening
pavlik harness = brace to prevent aDduction and hip extension
if treated in 1st few weeks good prognosis, otherwise juvenile OA likely
slipped capital femoral epiphysis
physis = growth plate
normal: hip growth plate changes orientation during development to better bear weight
increased stress on joint + risk factor e.g. Down’s, obese, hypothyroid –> head of femur shifts through growth plate (frx)
sharp, severe pain in groin, may radiate to butt and knee
worse with movement or weight-bearing
leg is in external rotation, limp
decreased internal rotation and aBduction
xray
requires surgical pinning
toxic synovitis of hip
idiopathic, transient synovitis
usually boys 3-7 y/o
acute pain, limp, sometimes inability to walk on affected limb most commonly in morning
generally not sick, CBC and ESR are normal
usually lasts 3-5 days
limited internal rotation of hip w/o pain on palpation
trochanteric bursitis
inflammation of bursa between greater trochater and glute max insertion
IT band tightens and puts pressure, friction on bursa
usually acute, repetitive trauma e.g. running
gradual onset lateral hip
initially deep and aching, progresses to constant deep
when severe may be associated with pain down IT band and at lateral insertion site on knee
sometimes bruising or swelling over lateral hip
pain over trochanteric bursa and IT band on palpation
IT stretching reproduces pain
groin or knee pain on internal rotation would suggest OA or other pathology NOT bursitis
normal XR
piriformis syndrome
local tenderness of piriformis with reproduction of sx on stretching or contraction of piriformis
causes of lateral hip/thigh pain
trochanteric bursitis: pain on palpation, +/- IT pain and tightness
lateral femoral cutaneous nerve syndrome: neuropathic, no pain on palpation
causes of groin pain in adults
OA: gradual, esp w/ old age
AVN: dx by MRI esp when risk factors present
causes of groin pain in kids
developmental hip dysplasia: newborn/infant
toxic synovitis: transient, 3-5 days, boys 3-7
legg calves perthes: AVN in boys 3-12
slipped capital femoral ephisys: adolescent boys esp obese, hypothyroid, Down’s
causes of buttocks pain
referred from lumbar disk ddd, radiculopathy, herniation
SI joint dysfunction: tenderness over ligaments
piriformis syndrome: piriformis spasm + sciatica
lateral femoral cutaneous nerve syndrome
meralgia paresthetica
compression of lateral femoral cutaneous nerve as it courses deep to lateral edge of inguinal ligament
burning, numbness, parethesias down proximal-lateral thigh
no motor sx (this is a sensory nerve)
causes: tight belts, seat belt injury, obesity
